Psychiatry’s list of disorders needs real-time updates


The Diagnostic and Statistical Manual of Mental Disorders — also known as the DSM and sometimes erroneously called the bible of psychiatry — is the authoritative guide to diagnosing depression, schizophrenia, and over a hundred other mental disorders. The latest version, published in 2013, was 19 years in the making. A new revision process put in place by the American Psychiatric Association, the DSM’s publisher, aims to make it easier for the manual to reflect changes in psychiatry.

Health care professionals in the United States and around the world rely on the DSM for descriptions and operational definitions for diagnosing mental disorders. It provides a common language clinicians can use to communicate about their patients. In addition, researchers can use its reliable definitions to help develop new medications and other treatments for mental health problems. Each edition of the DSM has sold over 1 million copies, indicating that it is also used by students learning about mental disorders as well as patients and their families who want to gain a better understanding of mental illnesses.

Revising the entire DSM every so often — the manual has been updated seven times since it was first published in 1952 — ensures that it keeps abreast with scientific developments in psychiatry. The overarching goal of these updates is to improve the manual’s validity, reliability, and clinical usefulness. Creating an update is a long, labor-intensive affair involving committees of experts with specific assignments aimed at overhauling the entire classification system.

Revising the entire manual at once helped ensure the uniformity and stability of the diagnostic information while that edition of the manual was in effect. But it made it difficult to incorporate new scientific knowledge in a timely fashion.

Advances in digital publishing that allow for instantaneous dissemination of changes at minimal cost have paved the way toward adopting a continuous improvement model for the DSM. Rather than updating all sections simultaneously, single entries can be updated pegged to specific scientific advances. Rather than waiting until the next scheduled revision to add a clinically useful change, such as incorporating a well-validated biomarker into the definition of a disorder, a change could be put into effect as soon as its clinical value has been verified.

This continuous improvement model will be entirely data driven. That will discourage changes that are not well supported by empirical evidence.

As my colleagues Dr. Kenneth S. Kendler and Dr. Ellen Leibenluft and I wrote last month in JAMA Psychiatry, the American Psychiatric Association (APA) is setting up a new web portal to field proposals for changes to the DSM. Individuals or groups making proposals must provide supportive information such as reasons for the change, data documenting improvements in validity, evidence of reliability and clinical utility, and a discussion of potentially harmful consequences associated with the proposed change. Proposals must also include a thorough review of the relevant literature and any secondary data analyses the proposers have conducted.

A steering committee appointed by the APA has defined four types of proposals: revising an existing diagnostic criteria set, adding a new diagnostic category, deleting an existing category, and correcting errors or inconsistencies.

We anticipate that most submissions will come from interested individuals, such as psychiatric researchers and clinicians, or from organizations such as psychiatric subspecialty groups and advocacy organizations. All of these submitters are separate from the committee overseeing the revision process. This is in marked contrast to earlier DSM revisions, in which the proposals were drafted by members of workgroups assembled by the APA, who were also responsible for reviewing the literature and reanalyzing data.

Putting in place a rigorous continuous improvement process for the DSM will let the manual reflect scientific advances more rapidly than was possible with the old revision process. This should ultimately result in a more valid and clinically useful diagnostic classification, which will help mental health providers and other clinicians to more accurately diagnosis and treat their patients.

Michael B. First, MD, is professor of clinical psychiatry at Columbia University and a member of the American Psychiatry Association’s DSM Steering Committee.